Preliminary applicability tests of different methacrylic acid copolymers, type C NF, particularly relevant to spreading and film formation

The intention of this study was to show under which conditions a film forming methacrylic acid copolymer coating excipient, corresponding to the requirements of pharmacopoeia, but obtained from different sources, can be substituted without severe problems. The mechanical properties of the film coats were investigated by dynamic-mechanical thermo-analysis (DMTA) experiments to determine with respect to the glass transition the storage modulus E', the loss modulus E'', and the loss factor tan delta. Further determinations concerned the surface tensions of the different coating dispersions. This attribute plays an important role in spreading, distribution and coalescence of the film forming preparations. Finally by a series of small experimental fluidized bed batches cores containing a model drug were coated with the different methacrylic acid copolymers. The resistance of these coated tablets in 0.1 N HC1 as well as their dissolution rates in artificial intestinal juice were tested. The coatings proved themselves so similar that in this case substitutions of products of different provenance are possible. The determinations of surface tension and the DMTA measurements seem to be useful and reliable preliminary applicability tests.

Inflammatory bowel diseases with onset in childhood. Clinical features, morbidity, and mortality in a regional cohort

BACKGROUND AND METHODS

In a geographically derived incidence cohort diagnosed from 1962 to 1987 we identified all patients with onset of inflammatory bowel diseases (IBD) before the age of 15 years, to describe the clinical course and to compare the course and prognosis with those of adult-onset IBD.

RESULTS

The mean incidence of IBD among children below 15 years was 2.2/10(5), 2.0 for ulcerative colitis (UC) and 0.2 for Crohn's disease (CD). At diagnosis children with UC had more extensive disease than adults (P < 0.05). Abdominal pain was also more frequent. The cumulative colectomy probability was 6% after 1 year and 29% after 20 years, not different from that of adults. More females underwent colectomy. With regard to disease activity, apart from the year of diagnosis 60-70% of UC patients were in remission in each of the first 10 years of disease; for CD about 50% were in remission. One patient with UC developed carcinoma of the sigmoid colon. Time between onset of UC and development of carcinoma was 12 years. For CD no differences in clinical appearance at diagnosis and course between children and adults were found in relationship to surgery. No deaths occurred among CD patients. Three CD patients were severely growth-retarded already at diagnosis.

CONCLUSION

The incidence of IBD is low in childhood. At diagnosis children with UC have more widespread disease than adults. Childhood-onset CD does not differ in clinical presentation, disease course, or prognosis from adult-onset CD. However, growth retardation is a problem among male CD patients.

Changes in extent of ulcerative colitis: a study on the course and prognostic factors

BACKGROUND

The prognosis of patients with ulcerative colitis (UC) has previously been described with regard to mortality, cancer occurrence, and need for colectomy on the basis of an annual follow-up of a regional cohort of UC patients in Copenhagen County diagnosed in 1962-87. The objective of this study was to examine the prognosis with regard to spread of disease and to evaluate possible prognostic factors with regard to spread of disease and colectomy by multivariate regression analysis.

METHODS

An inception cohort of 1161 patients with UC was examined by actuarial analysis and by multivariate regression analysis of a subgroup of 467 patients diagnosed in 1979-87.

RESULTS

The probability for further progression of proctosigmoiditis, evaluated by sigmoidoscopy and radiology, was 53% after 25 years. The probability for regression was 76.8% for substantial colitis and 75.7% for pancolitis after 25 years. Multivariate regression analysis showed that the occurrence of the symptoms abdominal pain and diarrhoea was prognostically unfavourable with regard to the progression from proctosigmoiditis. Age influenced the regression probability in extensive disease. With regard to colectomy the following variables influenced the prognosis: fever, general condition, serum albumin, mucopus in stools, and diarrhoea at onset.

CONCLUSIONS

Disease extent in UC is not static but changes with time in approximately half of the patients. This finding should have implications for the follow-up. Ulcerative proctitis should be considered the same disease as UC and needs the same long-term follow-up.

Familial occurrence and inheritance studies in inflammatory bowel disease

A number of studies have demonstrated aggregation of cases of ulcerative colitis or Crohn's disease in families, and of cases of both diseases within the same families, suggesting that patients share a genetic background. Perhaps because of differences in the selection of patients, study design and diagnostic criteria, different patterns of occurrence of inflammatory bowel disease (IBD) have been found among relatives of patients with these disorders. In recent years, however, several studies have been carried out, aiming by epidemiological methods to reveal (1) the frequency of familial occurrence of IBD among patients with ulcerative colitis and Crohn's disease, and (2) the prevalence of IBD among 1(0) relatives to patients with these diseases. Results from these studies show a relatively uniform pattern of family occurrence in about 10% of patients with ulcerative colitis and Crohn's disease, and a prevalence among 1(0) relatives of about 10 times that of the background population. A twin study reported a significantly higher concordance rate for Crohn's disease than for ulcerative colitis in monozygotic twins. By use of complex segregation analyses in 3 different studies, a very similar model of inheritance was found to fit for ulcerative colitis, namely a major dominant or additive gene with a low penetrance. For Crohn's disease the best-fitting model was a major recessive gene, with a high penetrance. This difference strongly supports the concept of ulcerative colitis and Crohn's disease as two separate disease entities. The occurrence of both diseases within the same families in certain members of the affected families is difficult to explain. The search for distinct associations of HLA genes with inflammatory bowel disease has shown a positive correlation between DR2 and ulcerative colitis and a negative association with DR4 and DRw6, compared with ethnically matched controls. In contrast, in Crohn's disease a positive association with the combination of DR1 and DQw5 alleles was revealed, thus indicating genetically different disease susceptibility for the two disorders. In general, however, no consistent pattern has been revealed from studies of association of HLA-A or -B antigens or blood group and serum protein markers. In two French families with several members affected with Crohn's disease no evidence for an HLA haplotype association could be revealed. Possible inherited markers of ulcerative colitis or Crohn's disease have been sought but without convincing success. Increased intestinal permeability, presence of anticolon antibodies and presence of antineutrophil leukocyte antibodies have been proposed, but not proved. Thorough studies are now needed of multimember families with disease for linkage studies to identify loci which contribute to increased liability. Such studies are in progress in different centres.

Epidemiology in gastroenterology

A review of the literature on gastrointestinal epidemiology during the last 25 years shows a comprehensive contribution from Danish studies. This is partly explained by very favourable conditions in Denmark for epidemiological research, due to various valid registers and a long tradition for longitudinal population and patient cohorts. Data are presented on prevalence, incidence, demography, clinical risk factors, clinical course, and prognosis of various gastrointestinal disorders. Main emphasis is put on Danish studies, which are compared with international results. Present possibilities for prophylaxis against gastrointestinal diseases and delimitation of treatment of benign diseases are discussed. It is expected that research within gastrointestinal epidemiology in Denmark will increase in the coming years.

Disease activity courses in a regional cohort of Crohn's disease patients

BACKGROUND

The study was a follow-up of an inception cohort of 373 patients with Crohn's disease.

METHODS

Annual assessments, life table analyses, and Markov chain analyses, estimating the probability for remission and relapse with time, and working capacity were carried out.

RESULTS

The clinical course of Crohn's disease differs markedly over time, from ever-relapsing cases to a quiescent course with remission for several years, interrupted by years with relapse. No predictive factors have been found for the subsequent course with regard to age, sex, extent of disease at diagnosis, and treatment in the year of diagnosis. The relapse rate within the year of diagnosis and the following 2 years, however, does correlate positively (p = 0.00001) with the relapse rate in the following 5 years. Furthermore, the relapse rate for 1 year during the disease course influences the relapse rate the following year, indicating a disease pattern over time with waves of at least 2 years' duration. A slight tendency towards burning out was found. The disease course reflected in working capacity for the patients showed that a minor part--up to 15% after 15 years--will become incapable and obtain disablement pension, while 75% of the patients each year are fully capable of work. Within 10 years 50% of the patients will not have experienced any year with impaired capacity for work.

Mycobacterium paratuberculosis in intestinal tissue from patients with Crohn's disease demonstrated by a nested primer polymerase chain reaction

BACKGROUND

The etiology of Crohn's disease remains unknown, but current research has concentrated on autoimmunity and/or mycobacterial infection. The polymerase chain reaction (PCR) enables the detection of genetic material even when very few microorganisms are present.

METHODS

A nested primer PCR for detection of a multi-copy insertional element (IS900) specific for Mycobacterium paratuberculosis was applied to DNA extracted from fresh and from paraffin-embedded intestinal tissue obtained from patients undergoing surgery.

RESULTS

In fresh intestinal tissue from 11 of 24 patients with Crohn's disease, from 2 of 10 patients with ulcerative colitis, and from 3 of 28 patients with other colonic disorders, specific M. paratuberculosis DNA was found. In paraffin-embedded Crohn's disease tissue the presence of specific M. paratuberculosis DNA was also increased.

CONCLUSIONS

Whether the presence of M. paratuberculosis is connected to the inflammatory bowel disease or is a mere coincidence cannot be stated. We find this presence interesting and encouraging for further investigations.

Course of ulcerative colitis: analysis of changes in disease activity over years

BACKGROUND/AIMS

The course and prognosis of ulcerative colitis (UC) are often reported in terms of mortality and cancer risk. This study examined the clinical course in terms of morbidity.

METHODS

A total of 1161 patients with UC were followed up from diagnosis up to 25 years. Actuarial analysis and Markov chain analysis were used to estimate the probabilities of remission and relapses during the disease course.

RESULTS

The distribution of disease activity was remarkably constant each year, with about 50% of patients in clinical remission. After 10 years, the colectomy rate was 24%. The cumulative probability of a relapsing course is 90% after 25 years of follow-up. The course of disease changed between remission and relapse without significant predictors, except for disease activity in foregoing years. In years 3-7 after diagnosis, 25% of patients were in remission; 18% had activity every year; and 57% had intermittent relapses. Activity in the first 2 years after diagnosis significantly correlated with having an increased probability of 5 consecutive years of disease activity (P = 0.00001). The probability of maintaining working capacity after 10 years was 92.8% (range, 90.8%-94.8%).

CONCLUSIONS

About half of patients with UC will be in remission at any time, although 90% have an intermittent course. Relapses are unpredictable except that disease activity in foregoing years indicates with 70%-80% probability that the disease will continue the following year. Although UC is troublesome, most patients' lives are relatively little influenced by it.

Frequency of glucocorticoid resistance and dependency in Crohn's disease

The outcome of the first steroid treatment course was prospectively studied in a regional cohort of 196 patients with Crohn's disease diagnosed 1979-1987. The immediate outcome after 30 days, and the prolonged outcome 30 days after treatment had stopped, are described. In all 109 patients treatment was analysed. Complete remission was obtained in 48%, partial remission in 32%, and no response in 20% within 30 days of treatment. Among primary responders (complete and partial remission), 55% remained in prolonged response after treatment had finished, while 45% relapsed or could not be withdrawn from treatment within one year. Localisation of disease, age, sex or clinical symptoms did not significantly correlate with outcome, which can be summarised as prolonged steroid response in 44%, steroid dependency in 36%, and steroid resistant in 20% of the patients.

Intestinal permeability in patients with Crohn's disease and ulcerative colitis and their first degree relatives

Increased intestinal permeability in patients with Crohn's disease and their first degree relatives has been proposed as an aetiological factor. The nine hour overnight urinary excretion of polyethyleneglycol-400 (PEG-400) and three inert sugars (lactulose, l-rhamnose, and mannitol) was used to test the permeation in 47 patients with Crohn's disease of whom 18 had at least one first degree relative with inflammatory bowel disease (2BD) and 52 patients with ulcerative colitis of whom 16 had at least one first degree relative with IBD. A total of 17 first degree relatives with IBD and 56 healthy first degree relatives were included. Thirty one healthy subjects not related to patients with IBD served as controls. No significant differences in PEG-400 permeation were found between the groups of patients, relatives, and controls, or between diseased and healthy relatives. The permeability to lactulose, rhamnose, and mannitol similarly did not differ between the three groups. This study challenges the previously reported findings of increased PEG-400 permeation in patients with Crohn's disease and in their healthy and diseased first degree relatives. There was no increase in permeability in a similar group of ulcerative colitis patients and their families.

Intestinal cancer risk and mortality in patients with Crohn's disease

BACKGROUND

It is important to know about mortality, risk of intestinal cancer, and surgical intervention as well as possible predictive factors for patients with Crohn's disease. These prognostic parameters were estimated by regular follow-up of a complete, regional incidence cohort of 373 patients.

METHODS

Annual assessments of clinical conditions were the basis for statistical evaluation with life table analysis, calculations of relative risk, and lifetime cancer risk.

RESULTS

Survival curves for the total group of patients with Crohn's disease and the background population did not differ. However, a subgroup of patients aged 20-29 years at diagnosis (P = 0.04) and a subgroup of patients with extensive small bowel disease (P = 0.03) showed slightly increased mortality within the first 5 years. Cancer in small and/or large bowel occurred in 3 patients vs. an expected 1.8(P = NS). Small bowel cancer was found in 2 patients vs. the 0.04 expected (P = 0.001). Lifetime risk of intestinal cancer was 4.1% compared with 3.8% for the Danish population in general (P = NS). Probability of surgical resection within 15 years after diagnosis was 70%. The initial extent of disease significantly influenced the probability for resection, which was 78% in ileocecal enteritis and 44% in all other localizations within 5 years after diagnosis.

CONCLUSIONS

The overall mortality and life-time risk of cancer in patients with Crohn's disease was not found increased, although the risk of rare small bowel cancer was significantly increased.

[Long-term prognosis of patients with ulcerative colitis]

A regional inception cohort of 1161 ulcerative colitis patients was followed from diagnosis to the end of 1987. Follow-up rate for death and occurrence of cancer was 99.9%. Median observation time 11.7 years, range 0-26 years. One hundred and forty-one deaths were observed, 26 due to ulcerative colitis or complications thereof. No significant excess mortality was found after the first year, but in the year of diagnosis the relative risk of death was 2.4 (p < 0.001). The cumulative colectomy rate was 32.4% 25 years after diagnosis. The initial extent of disease significantly influenced the colectomy probability, being 35% in total colitis, 19% in substantial colitis and 9% in distal colitis within the first five years after diagnosis. Six patients developed colorectal cancer within the observation period. Compared to the expected number of 6.6 the relative risk for patients with ulcerative colitis was 0.9. The calculated cumulative cancer incidence was 3.1% after 25 years (95% confidence limits 0.0-6.8). The calculated lifetime risk (0 to 74 years) for development of colorectal cancer was 3.5% for the patients compared to 3.7% for the Danish population. We conclude that with an active approach to medical and surgical treatment as was practiced here, those patients who are left with their colon intact bear no significantly increased risk of colo-rectal malignancy.

[Increased incidence of Crohn disease in the county of Copenhagen]

The incidence of Crohn's disease was assessed in a population based study in Copenhagen County from 1962-1987. The incidence increased six fold during the study period from 0.62/10(5) in 1962 to a mean of 4.1/10(5) from 1979-1987, equally in both sexes. The highest incidence was found in the age group 15-24 years: 12.8/10(5) for women and 6.0/10(5) for men (as mean of the period 1979-1987). The prevalence at the end of the study was 54/10(5). The clinical symptoms and extent of disease at diagnosis did not change over the time, but a significantly higher disease activity was found in the 1980's, 74% (1962-1979) vs 84% (1980-1987), p = 0.04. The increase in incidence of Crohn's disease is well established in most parts of the industrialized world. The analysis shows that it is not due to a new disease entity, since the extent of disease, the age and sex distribution, and the symptoms remained unchanged during the 26 year study period.

Investigation of inheritance of chronic inflammatory bowel diseases by complex segregation analysis

OBJECTIVE

To investigate the mode of inheritance of ulcerative colitis and Crohn's disease by complex segregation analysis.

DESIGN

Cross sectional population based survey of familial occurrence of chronic inflammatory bowel disease.

SETTING

Population of the Copenhagen county in 1987.

SUBJECTS

662 patients in whom inflammatory bowel disease had been diagnosed before 1979, of whom 637 (96%) provided adequate information. Of 504 patients with ulcerative colitis, 54 had 77 relatives with ulcerative colitis and of 133 patients with Crohn's disease, five had seven relatives with Crohn's disease.

MAIN OUTCOME MEASURES

Patterns of segregation of either disease as assessed by complex segregation analysis performed with the computer program POINTER.

RESULTS

The analysis suggested that a major dominant gene with a penetrance of 0.20-0.26 is present in 9-13% of adult patients with ulcerative colitis. The analysis did not allow for other components in the familial aggregation. For Crohn's disease the best fitting model included a major recessive gene with complete penetrance, for which 7% of the patients are homozygous. However, this model was not significantly different from a multifactorial model.

CONCLUSIONS

The segregation pattern indicates that a major dominant gene has a role in ulcerative colitis, and suggests that a major recessive gene has a role in Crohn's disease.

Colorectal cancer risk and mortality in patients with ulcerative colitis

A regional inception cohort of 1161 ulcerative colitis (UC) patients was followed up from diagnosis to the end of 1987. The follow-up rate for death and occurrence of cancer was 99.9% (median observation time, 11.7 years; range, 0-26 years). One hundred forty-one deaths were observed, 26 caused by UC or complications thereof. No significant excess mortality was found after the first year, but in the year of diagnosis the relative risk of death was 2.4 (P < 0.001). The cumulative colectomy rate 25 years after diagnosis was 32.4%. The initial extent of disease significantly influenced the colectomy probability, being 35% in total colitis, 19% in substantial colitis, and 9% in distal colitis within the first 5 years after diagnosis. Six patients developed colorectal cancer within the observation period. Compared with the expected number of 6.6, the relative risk for patients with UC was 0.9. The calculated cumulative cancer incidence was 3.1% after 25 years (95% confidence limits, 0.0-6.8). The calculated lifetime risk (0-74 years) for development of colorectal cancer was 3.5% for UC patients compared with 3.7% for the Danish population. It is concluded that with an active approach to medical and surgical treatment, as practiced here, patients whose colons are left intact bear no significantly increased risk of colorectal malignancy.

Treatment of Crohn's disease with fusidic acid: an antibiotic with immunosuppressive properties similar to cyclosporin

Fusidic acid is an antibiotic with T-cell specific immunosuppressive effects similar to those of cyclosporin. Because of the need for the development of new treatments for Crohn's disease, a pilot study was undertaken to estimate the pharmacodynamics and tolerability of fusidic acid treatment in chronic active, therapy-resistant patients. Eight Crohn's disease patients were included. Fusidic acid was administered orally in a dose of 500 mg t.d.s. and the treatment was planned to last 8 weeks. The disease activity was primarily measured by a modified individual grading score. Five of 8 patients (63%) improved during fusidic acid treatment: 3 at two weeks and 2 after four weeks. There were no serious clinical side effects, but dose reduction was required in two patients because of nausea. Biochemically, an increase in alkaline phosphatases was noted in 5 of 8 cases (63%), and the greatest increases were seen in those who had elevated levels prior to treatment. All reversed to pre-treatment levels after cessation of treatment. The results of this pilot study suggest that fusidic acid may be of benefit in selected chronic active Crohn's disease patients in whom conventional treatment is ineffective. Because there seems to exist a scientific rationale for the use of fusidic acid at the cytokine level in inflammatory bowel disease, we suggest that the role of this treatment should be further investigated.

Incidence and prevalence of Crohn's disease in the county of Copenhagen, 1962-87: a sixfold increase in incidence

The incidence of Crohn's disease increased sixfold from 1962 to 1987 in the county of Copenhagen. The mean annual incidence for 1979-87 was 4.1 per 10(5) inhabitants. The increase was found equally in both sexes, with an approximately 40% higher incidence in women. The maximal incidence was found in the 15- to 24-year age group, being 12.8 per 10(5) per year for women and 6.0 per 10(5) per year for men, as mean of the period 1979-87. The prevalence at the end of the study was 54 per 10(5) inhabitants, 46 per 10(5) in men and 63 per 10(5) in women. The clinical appearance of the disease at the time of diagnosis was remarkably similar during the study period with regard to both the localization of disease and the clinical symptoms and signs. A slightly higher percentage of the patients, however, were in high disease activity at diagnosis in the later years of the study.

Leucocyte scintigraphy to localize inflammatory activity in ulcerative colitis and Crohn's disease

The validity of using autologous leucocytes labelled with technetium -99m hexamethyl-propyleneamine-oxine (Tc-HMPAO) for scintigraphy in inflammatory bowel disease was evaluated in 12 patients with clinically active ulcerative colitis (UC) and 10 with Crohn's disease (CD). Colonoscopy and biopsy were used as reference. Scintigrams taken 1 h and 3 h after leucocyte reinjection were evaluated blindly by two independent observer groups. Full agreement was found in 11 of 12 UC patients when compared with colonoscopy but in only 3 of 10 CD patients. Segments with agreement in CD patients often showed neutrophilic granulocyte infiltration at biopsy. The judgements of clinicians and physiologists differed for only 2 of totally 70 UC segments but for 13 of 59 CD segments (kappa, 0.94 and 0.52). It is concluded that Tc-HMPAO scintigraphy might be an alternative to colonoscopy in the control of disease extent in UC. In CD patients the technique might warn about infections complications.

Incidence and prevalence of ulcerative colitis in Copenhagen county from 1962 to 1987

The incidence of ulcerative colitis was estimated during the period 1962 to 1987 in the county of Copenhagen. Within this area of approximately 550,000 inhabitants, 1161 patients were diagnosed. The mean annual incidence for the period was 8.1 per 10(5) inhabitants. There were significant increases in incidence in the early 1970s and in the early 1980s, both of which were followed by significant decreases. A bimodal age distribution was found in men, with incidence peaks in young adult life and late in life. In women a peak incidence was found in the young adult age group. The interval from onset of symptoms to diagnosis in terms of years remained unchanged over the period, with a median of 1 year (range, 0-37 years). The extent of disease at diagnosis was total colon in 18% of the patients, a substantial part of the colon in 36%, and distal colon in 44%--with no changes during the study period. The distribution of different localizations did not differ among age groups except for a tendency towards more extensive disease in young patients, below 20 years of age. The disease activity in the 1st year was fulminant in 9.1% of the cases, moderate to high in 70.7%, and low in 20.2%, with a tendency towards higher activity in patients diagnosed late in the study period. The prevalence of ulcerative colitis increased steadily during the study period, reaching a value at the end of the study (31 December 1987) of 161 per 10(5) inhabitants.

Granulomas of the appendix: is it Crohn's disease?

An epidemiologic study was performed 1) to estimate the occurrence of epithelioid granulomas in the appendix wall among patients in whom an appendectomy had been performed, 2) to identify patients with granulomas in the appendix who had symptoms and history compatible with Crohn's disease, and 3) to estimate the long-term prognosis. Within a 5-year period 6051 patients in Copenhagen County underwent appendectomy. Six patients (0.1%) had epithelioid granulomas of the appendix (0.2 per 10(5) inhabitants per year). Follow-up of the six patients for 9-11 years (median, 9.5 years) showed that all had been free of gastrointestinal symptoms since the operation. Among the 373 patients diagnosed as having Crohn's disease in Copenhagen County between 1962 and 1987, 3 patients had their disease initially confined to the appendix. Follow-up in these patients showed no recurrence within a median of 6 years (range, 4-7 years). Patients with epithelioid granulomas of the appendix have an excellent long-term prognosis, which could be explained by the fact that the condition seems to be unrelated to Crohn's disease.

Colonic epithelial dysplasia or carcinoma in a regional group of patients with ulcerative colitis of more than 15 years duration

Colonoscopic screening for neoplasia was performed in a regional group of ulcerative colitis patients with a disease duration of greater than or equal to 15 years. A total of 121 patients, aged less than 80 years, were invited to participate, of whom 100 (83%) accepted colonoscopy, including biopsies in 15 standard locations of the entire colon, plus additional biopsies from all visible lesions. Unequivocal dysplasia was found in one patient with extensive colitis and a disease duration of 31 years. A polyp with highly differentiated adenocarcinoma was found in the sigmoid colon of a patient with intermittent rectum involvement, 37 years after the ulcerative colitis diagnosis had been made. Biopsy specimens from the remaining 98 patients showed no signs of dysplasia or cancer. Thus the frequency of pre-malignant or malignant changes is very low compared with the results of similar studies, and the rationale for general colonoscopic surveillance programmes for such patients is open to question.

Familial occurrence of inflammatory bowel disease

BACKGROUND AND METHODS

We assessed the familial occurrence of inflammatory bowel disease in Copenhagen County, where there has been a long-term interest in the epidemiology of such disorders. In 1987 we interviewed 662 patients in whom inflammatory bowel disease had been diagnosed before 1979, asking whether their first- and second-degree relatives had this disorder. Ninety-six percent of the patients (504 with ulcerative colitis and 133 with Crohn's disease) provided adequate information.

RESULTS

As compared with the general population, the first-degree relatives of the 637 patients with ulcerative colitis or Crohn's disease had a 10-fold increase in the risk of having the same disease as the patients, after standardization for age and sex. The risk of having the other of the two diseases was also increased, but less so, and the increase in the risk of having Crohn's disease was not significant in the relatives of patients with ulcerative colitis. The risk of ulcerative colitis in first-degree relatives of patients with ulcerative colitis appeared to be virtually independent of the generation to which the first-degree relative belonged and of the sex of the patient and the relative. The risk of ulcerative colitis in first-degree relatives tended to be higher if the disease had been diagnosed in the patient before the age of 50, but the risk seemed to be independent of the current age of the relatives. The prevalence of the same disease as that of the patient (either ulcerative colitis or Crohn's disease) among second-degree relatives was increased; the prevalence of the other disease was not increased.

CONCLUSIONS

The 10-fold increase in the familial risk of ulcerative colitis and Crohn's disease strongly suggests that these disorders have a genetic cause.

Prevalence of hepatobiliary dysfunction in a regional group of patients with chronic inflammatory bowel disease

A regional group of outpatients with chronic inflammatory bowel disease (ulcerative colitis, n = 396, and Crohn's disease, n = 125) was biochemically screened to estimate the prevalence of hepatobiliary dysfunction. Among the 396 patients with ulcerative colitis, 69 (17%; 95% confidence limits, 14-22%) had at least 1 abnormal laboratory value. Serum bilirubin was elevated in 5%, alkaline phosphatases in 8%, aspartate aminotransferases in 4%, and alanine aminotransferases in 8% of the patients. Two per cent had decreased plasma coagulation factors (2.7 and 10) and serum albumin. Further diagnositc evaluation consisting of ultrasonography, liver biopsy, and endoscopic retrograde cholangiography was performed in patients who had biochemical values more than twice the upper normal limit in two consecutive blood tests within a fortnight. Six patients (1%) fulfilled this criterion. Three patients had primary sclerosing cholangitis, of whom two were primarily diagnosed; one patient had cholangiocarcinoma also primarily diagnosed; and two patients were found to have alcoholic hepatic damage. Among the 125 patients with Crohn's disease, 38 (30%; 95% confidence limits, 23-38%) had at least 1 abnormal laboratory value. Serum bilirubin was elevated in 2%, alkaline phosphatases in 18%, asparetate aminotransferases in 3%, and alanine aminotransferases in 10% of the patients. One per cent had decreased plasma coagulation factors (2.7 and 10) and serum albumin concentrations. Three patients (2%) fulfilled the criteria for further evaluation as described above. One patient appeared to have epithelioid granuloma in the liver and one patient had alcoholic liver disease, whereas one patient refused further examination.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical evidence supporting the radical scavenger mechanism of 5-aminosalicylic acid

5-Aminosalicylic acid, the therapeutically active metabolite of sulfasalazine, was exposed to oxygen-derived free radicals produced by the Fenton reaction in vitro, and several metabolites were detected and characterized by high performance liquid chromatography and ultraviolet spectrophotometry. The majority of these metabolites were present in methanolic extracts of feces samples from sulfasalazine-treated patients with inflammatory bowel disease but not in rheumatoid arthritis patients with normal bowel function. The presence of these metabolites, which have not been demonstrated in vivo before, provides evidence of an interaction between 5-aminosalicylic acid and oxygen-derived free radicals in sulfasalazine-treated patients with inflammatory bowel disease. Since the concentration of lipid peroxides, which is dependent on the release of oxygen-derived free radicals, was significantly increased in pretreatment rectal biopsies of the patients, and further was normalized concomitantly with a significant improvement in disease activity over the 5-wk treatment period, an important role of the radical scavenger mechanism of 5-aminosalicylic acid in sulfasalazine therapy of chronic inflammatory bowel disease is strongly suggested.

Lifelong control with inflammatory bowel disease patients

The benefits and the burden of a lifelong control scheme for patients with chronic inflammatory bowel disease are discussed. The benefits cover physical, psychologic, and social conditions. Valuable scientific gains can be yielded secondarily from the data collection.

Elemental diet: a therapeutic approach in chronic inflammatory bowel disease

The therapeutic effect of an elemental diet (Pepti 2000) and blended normal diet (placebo) was investigated in 43 out-patients with chronic inflammatory bowel disease (IBD); 24 with ulcerative colitis (UC) and 19 with Crohn's disease (CD), in a mild to moderate state of disease activity. A pilot study on healthy volunteers was executed to investigate palatability of the two diets. The patients were randomized in a double-blind study to the two diet regimes for 14 d. A simultaneous determination of laboratory data including plasma C3c split product and urinary excretion of 51Cr-EDTA was carried out together with a careful registration of the clinical symptoms and signs. No significant effect on the stage of clinical activity was seen in CD. A significant effect on clinical activity was obtained in both UC groups. The clinical improvement was primarily due to a decrease in number of bowel movements both in the elemental diet group and in the group of patients on the blended normal diet. The gross appearance of rectal mucosa did not improve during the study period in the Pepti 2000 or in the placebo group. The concentration of complement split products in plasma remained unchanged. 51Cr-EDTA excretion, as an expression of a leaky bowel mucosa, also remained unchanged. It was concluded that an effect on inflammation could not be demonstrated even if both diets seem to have a beneficial effect on the stage of clinical activity, especially diarrhoea, in patients with UC.

Low-dose cyclosporin for Crohn's disease: implications for clinical trials

Cyclosporin is a potent immunosuppressant, which has gained recent interest as a possible treatment for Crohn's disease. Chronic nephrotoxicity, however, has recently been demonstrated as a result of early treatment with high initial cyclosporin doses. We report the effect of a 3-month treatment with low-dose cyclosporin (5-7.5 mg kg-1 day-1) in 11 chronically active, therapy-resistant Crohn's disease patients. Eight of the 11 patients (72%) improved according to a clinical grading score and the Dutch Activity Index whereas 9/11 (82%) improved according to the Crohn's Disease Activity Index (P less than 0.05) after 1 month. Three patients were withdrawn despite clinical improvement. One developed arterial hypertension, one dropped out and one required surgical treatment due to a small bowel stricture. Five patients (45%) completed the treatment period with improved clinical scores. After tapering-off, two patients (18%) were better at follow-up. No serious side-effects were encountered and it is concluded that low-dose cyclosporin treatment should be further investigated in Crohn's disease.

Incidence of colonic cancer in inflammatory bowel disease

In a cohort of 783 regional patients with ulcerative colitis treated in specialized clinics from the onset of the disease, the intestinal cancer risk was estimated. Seven patients developed colonic cancer from 4 to 44 years after onset of disease (median, 14 years). Eighteen years after onset of the disease the calculated risk was 1.4% (0.7-2.8%). After completing this follow-up study a new study was carried out with colonoscopy of all long-standing cases (greater than or equal to 15 years) of ulcerative colitis which had not been operated on. Of 100 patients examined, 2 showed epithelial dysplasia, and 98 did not. In a similar cohort of 185 patients with Crohn's disease, 1 showed small-bowel cancer. This gives a calculated risk of 0.6% (0.1-3.1%) at 10 years after the disease onset.

Epidemiology, course and socio-economic influence of inflammatory bowel disease

Based on the literature and on our own experience from a follow-up study of all inflammatory bowel disease patients in a defined population, the epidemiology, course and social economic aspects of the diseases are discussed. The incidence of ulcerative colitis has shown geographical differences with a stable incidence in Stockholm, Cardiff, the United Kingdom and Copenhagen compared to a remarkable increase in incidence in Iceland, Faroe islands, Norway, Scotland and North Tees since 1970. For Crohn's disease there has been an overall increase in incidence in all studies with a tendency towards a plateau in recent years in some areas. The prevalence of ulcerative colitis in 1978 was 117/10(5) and for Crohn's disease 34/10(5) in Copenhagen county. The survival of the patients did not differ from that of the background except for a small excess mortality in elderly men with ulcerative colitis within the first 2 years with the disease. 10% of patients with ulcerative colitis were colectomized within 1 year and 23% within 10 years. 55% of patients with Crohn's disease were operated on within 10 years, 11% two or more times. The number of patients in complete remission for 10 years after the initial attack is practically zero. 90% of patients with ulcerative colitis and about 80% with Crohn's disease have full work capacity. The risk of intestinal cancer is 1.4% in ulcerative colitis after 18 years (e.g. twice the risk in the background population) and is markedly lower than in previous reports. In Crohn's disease no increased risk of cancer was found.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognosis and quality of life in patients with ulcerative colitis and Crohn's disease

The prognosis of a disease depends on individual social and medical factors. Prognosis for a group of patients on a well-defined treatment regimen will provide useful information only if patient material is suitable. In such studies normal survival of patients with ulcerative colitis and Crohn's disease has been reported. The price for good survival seems to be early surgical treatment in medical treatment failures. The quality of life (family relations, marriage, social activities and employment) did not differ significantly from a control group.

5-Aminosalicylic acid in the treatment of Crohn's disease. A 16-week double-blind, placebo-controlled, multicentre study with Pentasa

The response to 5-aminosalicylic acid (5-ASA) in mild and moderately active Crohn's disease localized in the small bowel was studied in a randomized, double-blind, placebo-controlled trial in four centres. Sixty-seven patients were included, of whom 30 were treated with 1500 mg slow-release 5-ASA/day (Pentasa) for a scheduled period of 16 weeks. In the 5-ASA group 40% of the patients improved, versus 30% of the placebo-treated group ('intent to treat' basis; p greater than 0.1). Four of the patients treated with 5-ASA left the study owing to disease deterioration, versus 10 of the placebo-treated patients (p greater than 0.2). Seventeen patients were secondarily excluded, and the remaining 50 patients (23 receiving 5-ASA) were reevaluated in greater detail. No statistically significant differences in outcome were shown. Three patients (one given 5-ASA) were withdrawn from the study because of presumed side effects, but no serious adverse reactions were recorded. The present results indicate that 5-ASA, at least in the dosage used, is not superior to placebo. Nevertheless, trends towards a beneficial effect in Crohn's disease in the small bowel justify further clinical trials with a larger dosage of 5-ASA.

CEA and carbohydrate antigens in normal and neoplastic colon mucosa. An immunohistochemical study

Antibodies raised against tumour-associated antigens have been assessed for tumour selectivity using an indirect immunohistochemical peroxidase staining of formalin-fixed, paraffin-embedded tissue from colon carcinomas, colon polyps and normal mucosa. The following antibodies were used: 1) Unabsorbed polyclonal antibody to carcinoembryonic antigen (poly-CEA). 2) Monoclonal antibodies to CEA (mabs 3851 and 27). 3) Monoclonal antibodies to protein-bound carbohydrates (mabs C 216 and C 242) or to lipid- and protein-bound carbohydrates (C 50 and 19-9). These antibodies had been produced by hybridization of lymphocytes from mice, immunized with colon carcinoma cell lines or colon cancer tissue. All antibodies were used in one concentration only, preselected by initial titration experiments. No antibody was completely tumour-specific, but four antibodies, mabs 3851, 27, C 216 and C 242, showed statistically significant tumour selectivity. Using these antibodies, respectively 19, 19, 19, and 18 of 20 colon cancer were stained compared with 3, 4, 4, and 8 of 15 specimens of colon mucosa from normal controls. An increased frequency of staining was also noted in dysplastic polyps (statistically significant using mabs 3851 and C 216) and in dysplastic mucosa adjacent to a tumour (statistically significant using mabs 3851 and 27). The staining frequency of normal colon mucosa in cases of colon cancer did not differ from that in the normal controls. Poly-CEA and the anti-ganglioside mabs C 50 and 19-9 revealed no tumour selectivity. A pronounced goblet cell staining was seen using C 50, C 242 and 19-9.

Life prospects and quality of life in patients with Crohn's disease

A regional prevalence group of 106 patients with Crohn's disease were interviewed about their familial, social, and professional conditions. The results were compared with results from similar interviews of an age and sex matched control group of 75 previously healthy patients admitted to the hospital for acute diseases of less than 28 days' duration. An equal percentage of the patients and the controls were married (67% vs 71%) and had become parents (68% vs 79%). The number of children was slightly lower among Crohn's disease patients. The occurrence of familial problems and sexual problems did not differ among patients and controls. The intake of sedatives was low in both groups and no difference was found in alcohol and tobacco intake between patients and controls. A combined score for social activities comprising cultural, sporting, educational and private social arrangements showed that about one-third of patients and controls had high social activity and about half of both groups had moderately high social activity. A similar physical activity score showed no difference between the two groups. The socioeconomic level of the Crohn's disease patients was slightly, but significantly higher than that of the controls. Sixty five per cent of Crohn's disease patients were employed, 64% of controls; 6% and 7% respectively unemployed. Three per cent of Crohn's disease patients had disablement pension. Of Crohn's disease patients employed, a higher percentage (77%) had remained in the same job for more than five years (64% of controls). The number of sick leave days during previous year was less than 11 in 72/69% of patients and controls. In spite of these objectively good results 54% of patients with Crohn's disease felt exacerbations of their disease strained their professional and personal life. During the previous year 23% reported decreased working capacity and 21% reported decreased leisure activities, compared with their own expectations.

The value of dynamic ultrasound scanning in Crohn's disease

In a prospective, blinded study we investigated 30 patients with Crohn's disease (CD) and 27 normal controls by means of dynamic grey-scale ultrasound scan. Within a few weeks the patients were also examined by radiography of the small bowel. Of the 30 patients, 21 had CD lesion of the small bowel as judged by radiography. A target lesion at the ultrasound scan indicating thickened bowel wall was seen in 15 CD patients, of which 14 showed radiographic signs of CD in the ileum and/or right side of the large bowel, whereas one had normal radiographic findings. Seven patients out of 15 without sonographic changes had radiographic signs of CD. The patients with discrepancy between the two examinations could not be clinically characterized as an entity. None of the 27 normal controls showed signs of intestinal disease at the ultrasound examination. We conclude that dynamic grey-scale ultrasound examination is a new tool in depicting the CD lesion, but it does not seem to be able to replace the radiographic examination. However, it may find a place in the follow-up study of patients with known CD, thereby avoiding repeated radiographic examinations. Furthermore, the possibility of diagnosing abscesses and fistulae by sonography is well known and has relevance in CD.

Steady-state kinetics of 5-aminosalicylic acid and sulfapyridine during sulfasalazine prophylaxis in ulcerative colitis

Fifteen adult and 19 pediatric outpatients with ulcerative colitis were studied to determine the steady-state kinetics of 5-aminosalicylic acid (5-ASA) released from salazosulfapyridine (SASP). Results of excretion in adults (mean 24-h recovery of 5-ASA, 21% in urine and 57% in feces) were compatible with those of healthy volunteers. Since mean SASP dose/kg body weight (about 50 mg/kg) and compliance (reflected in sulfapyridine recovery) were equal in adults and pediatric patients, the results of the patient groups could be compared. Near-complete azo reduction of SASP occurs in children. Absorption and excretion of 5-ASA and metabolism to acetyl-5-ASA did not differ statistically between pediatric and adult patients. However, the fecal excretion of the drug and its metabolites was significantly lower in young patients, although fecal concentrations were the same. The present results demonstrate that SASP is an excellent sustained-release drug for the delivery of 5-ASA to the lower part of the bowel system and provide a reference for comparison of 5-ASA kinetics after treatment with newer 5-ASA preparations.

Bile acid metabolism in patients with Crohn's disease in terminal ileum

Bile acid metabolism was studied by means of the fractional turnover rate or orally ingested 14C-labeled taurocholic acid and by gas chromatographic determination of fecal excretion of the bile acids cholic acid (CA), chenodeoxycholic acid (CDCA), deoxycholic acid (DCA), and lithocholic acid (LCA). Thirty patients with Crohn's disease (CD) of the small bowel, of whom 19 had been operated on with limited ileal resections, were studied and compared with 11 healthy volunteers. The unoperated group of CD patients did not show significant increase in bile acid excretion in the stools in contrast to the CD patients with ileal resection. The fecal excretion consisted mostly of primary bile acids, and a significant correlation between length of resection and bile acid excretion was found (rs = 0.81, p less than 0.01). The fractional turnover rate of CA + DCA was significantly increased in both unoperated (0.21 l/day) and operated (0.44 l/day) patients compared with normal controls (0.06 l/day). The bile acid pool of CA + DCA, however, was normal in patients with ileal resections, indicating a compensatory increase in bile acid synthesis. In unoperated patients the bile acid pool of CA + DCA was slightly decreased (3.1 mmol) compared with operated patients (6.2 mmol) and normal controls (4.8 mmol). The pool size was not significantly correlated to mean transit time of dietary residue, feces excretion, loss of weight, or amount of fat in feces. The mean transit time of dietary residue was decreased in both operated and unoperated CD patients.

Bile acid malabsorption in patients with an ileum reservoir with a long efferent leg to an anal anastomosis

Biliary metabolism in 11 patients with ileum reservoirs with anal anastomosis and a long efferent leg was studied. Eleven healthy persons served as controls. A significantly higher excretion of bile acids was found in the patients, but they seemed to have a normal cholic acid pool size. The bile acids excreted were cholic acid and chenodeoxycholic acid, the so-called primary bile acids, for more than 90%, whereas the normal controls mainly excreted secondary bile acids (deoxycholic acid and lithocholic acid). Fat excretion was generally not increased in the group but was above normal in two patients. Vitamin B12 absorption was subnormal in two patients and was not correlated to bile acid excretion. Bile acid excretion was not correlated to the weight of feces. The bacterial flora was more feces-like than would have been expected from a normal terminal ileum but was correlated neither to the bile acid excretion nor to the quantity of feces. We conclude that the patients showed dysfunction of the terminal ileum with regard to biliary acid absorption comparable to that found in patients with partial ileal resections.

Long term prognosis in ulcerative colitis--based on results from a regional patient group from the county of Copenhagen

The prognosis of ulcerative colitis including survival, colectomy rate, activity of disease, and working capacity was estimated from a follow up study of 783 patients with ulcerative colitis comprising all patients from the county of Copenhagen, except for the island of Amager, diagnosed between 1960 and 1978. The period of observation ranged from one to 18 years with a median of 6.7 years for the clinical observations, eight years for survival and 11.6 years for the occurrence of large bowel cancer. The follow up was 100% for both survival and cancer. The survival rate in women did not differ from that in the general population. In men over 40 years of age at diagnosis a slight excess mortality was found, but only in the year of diagnosis (2.1%) and the following year (1.5%). Colonic cancer was seen in only seven out of the 783 patients, corresponding to an annual risk of 0.07% and a cumulative risk after 18 years with ulcerative colitis of 1.4% (95% confidence limits, 0.7-2.8%) independent of the initial extent of disease. The colectomy rate was 9.6% in the year of diagnosis. The cumulative 10- and 18-year colectomy rate was 23% and 31%, respectively. After three years from diagnosis the capacity for work both in those subject to resection and treated conservatively did not differ significantly from that in the background population. At any time about 50% of the patients were without symptoms, in about 30% the disease activity was low and in about 20% moderate or high. Most patients, however, differed in activity from one year to another and almost all patients (97%) experienced at least one relapse during a 10 year time period.

Familial occurrence of complement dysfunction in Crohn's disease: correlation with intestinal symptoms and hypercatabolism of complement

Complement was studied in Crohn's disease probands with early onset and in their first degree relatives. Controls included 24 healthy volunteers and 24 patients with ulcerative colitis or peptic ulcers. Subnormal generation of chemotactic activity by the alternative pathway was shown in eight of 21 probands and in six of 33 relatives, a frequency in both groups significantly different from controls (p less than 0.005), with a strong connection between findings in patients and relatives. As previously shown in patients with Crohn's disease, the subnormal generation was related to decreased utilisation of complement C3 in relatives. Raised levels of circulating complement C3c split products suggested complement involvement in Crohn's disease probands. In contrast, plasma C3c was normal in all relatives, and none of the six cases with complement dysfunction had gastrointestinal symptoms or a history of inflammatory bowel disease. Our data suggest, that complement abnormality seen in Crohn's disease patients does not simply reflect mucosal inflammation or hypercatabolism of complement.

Prognosis in Crohn's disease--based on results from a regional patient group from the county of Copenhagen

All patients in the county of Copenhagen (approximately 500 000 inhabitants) with Crohn's disease, n = 185 were followed regularly between 1960 and 1978. The survival, the course of disease, the frequency of surgery, and the working capacity were estimated for the first 10 years of disease on the basis of the follow up results. The observation time ranged from 1-18 years with a median of 5.5 years for clinical observations, 5.8 years for survival, and 9.5 years for the occurrence of gastrointestinal cancer. The follow up was 100% concerning survival and cancer. The survival did not differ from that of the age- and sex-matched background population. Cancer was seen in only one of 185 patients corresponding to an annual risk of 0.06% and a cumulated risk after 10 years of 0.56, 95% confidence limits: 0.1-3.1%. The cancer was localised in the ileum. For all years, about 45% of the patients were without clinical symptoms of their disease, in 30% the clinical disease activity was low, and in 25% moderate to high. Among the patients with active disease, the course within the individual year was continuous in about one third and intermittent in about two thirds. After 10 years, 99% of the patients had experienced at least one relapse. The operation rate was 33% in the year of diagnosis, 13% in the following year, and then about 3% per year independent of whether or not the patient had been treated surgically in the past. After 10 years, 45% of the patients had not been treated surgically, 42% had had only one operation, and 13% had had two or more operations for their Crohn's disease. The working capacity was normal in about 75% of the patients for all years except the year of diagnosis. About 15-20% of the patients who had had the disease for more than five years were disabled as compared with about 4.4% of the background population. These results indicate that some of the patients with Crohn's disease run a more serious course with continuing symptoms despite of medical treatment and frequent surgical interventions. Most patients, however, remained capable for work and were able to lead a normal life.